Aetna Medicare Advantra Central Value (PPO), Aetna Medicare Advantra Credit Value (PPO),

Aetna Medicare Advantra Preferred Plan (PPO), Aetna Medicare Advantra Silver (PPO), Aetna

Medicare Advantra Value (PPO), Aetna Medicare Choice II Plan (PPO), Aetna Medicare Choice

Plan (PPO), Aetna Medicare Credit Plan (PPO), Aetna Medicare Discover Value Plan (PPO),

Aetna Medicare DMG Prime (PPO), Aetna Medicare Elite (PPO), Aetna Medicare Elite Plan

(PPO), Aetna Medicare Elite Plan 2 (PPO), Aetna Medicare Elite Plan 3 (PPO), Aetna Medicare

Essential Elite Plan (PPO), Aetna Medicare Essential Plan (PPO), Aetna Medicare Explorer Elite

(PPO), Aetna Medicare Explorer Plan (PPO), Aetna Medicare Explorer Premier (PPO), Aetna

Medicare Explorer Premier 2 (PPO), Aetna Medicare Explorer Premier Plan (PPO), Aetna

Medicare Explorer Premier Plus (PPO), Aetna Medicare Explorer Value (PPO), Aetna Medicare

Freedom Core Plan (PPO), Aetna Medicare Freedom Plan (PPO), Aetna Medicare Freedom

Preferred Plan (PPO), Aetna Medicare Gold Plan (PPO), Aetna Medicare Platinum Plan (PPO),

Aetna Medicare Plus Plan (PPO), Aetna Medicare Preferred Premium Plan (PPO), Aetna

Medicare Premier (PPO), Aetna Medicare Premier (Regional PPO), Aetna Medicare Premier 1

(PPO), Aetna Medicare Premier 2 (PPO), Aetna Medicare Premier Plan (PPO), Aetna Medicare

Premier Plus (PPO), Aetna Medicare Premier Plus 2 (PPO), Aetna Medicare Premier Plus 2

(Regional PPO), Aetna Medicare Premier Plus Plan (PPO), Aetna Medicare Prime (PPO), Aetna

Medicare Prime 1 (PPO), Aetna Medicare Prime Credit (PPO), Aetna Medicare Prime Premier

(PPO), Aetna Medicare Select Plan (PPO), Aetna Medicare SNJ Prime Elite (PPO), Aetna

Medicare The Valley Plan (PPO), Aetna Medicare Value (PPO), Aetna Medicare Value Plan

(PPO), Aetna Medicare Value Plus Plan (PPO)

Last Updated: 04/01/2022

ABIRATERONE

Products Affected

• Abiraterone Acetate

• Zytiga TABS 500MG

NR_0009_3741 09/2014

Formulary ID: 22007: version 12 1

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Node-positive (N1), non-metastatic (M0) prostate cancer

Exclusion

Criteria

N/A

Required

Medical

Information

The requested drug will be used in combination with a gonadotropin-

releasing hormone (GnRH) analog or after bilateral orchiectomy.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

2

ACITRETIN

Products Affected

• Acitretin

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Prevention of non-melanoma skin cancers in high risk individuals, Lichen

planus, Keratosis follicularis (Darier Disease)

Exclusion

Criteria

N/A

Required

Medical

Information

Psoriasis: The patient has experienced an inadequate treatment response,

intolerance, or the patient has a contraindication to methotrexate or

cyclosporine.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

3

ACTIMMUNE

Products Affected

• Actimmune

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Mycosis fungoides, Sezary syndrome.

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

4

ADEMPAS

Products Affected

• Adempas

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For pulmonary arterial hypertension (PAH) (World Health Organization

[WHO] Group 1): PAH was confirmed by right heart catheterization. For

PAH new starts only: 1) pretreatment mean pulmonary arterial pressure is

greater than 20 mmHg, AND 2) pretreatment pulmonary capillary wedge

pressure is less than or equal to 15 mmHg, AND 3) pretreatment

pulmonary vascular resistance is greater than or equal to 3 Wood units.

For chronic thromboembolic pulmonary hypertension (CTEPH) (WHO

Group 4): 1) Patient has persistent or recurrent CTEPH after pulmonary

endarterectomy (PEA), OR 2) Patient has inoperable CTEPH with the

diagnosis confirmed by right heart catheterization AND by computed

tomography (CT), magnetic resonance imaging (MRI), or pulmonary

angiography.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

5

AIMOVIG

Products Affected

• Aimovig

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

1) The patient received at least 3 months of treatment with the requested

drug, and the patient had a reduction in migraine days per month from

baseline, OR 2) The patient experienced an inadequate treatment response

with a 4-week trial of any of the following: Antiepileptic drugs (AEDs),

Beta-adrenergic blocking agents, Antidepressants, OR 3) The patient

experienced an intolerance or has a contraindication that would prohibit a

4-week trial of any of the following: Antiepileptic drugs (AEDs), Beta-

adrenergic blocking agents, Antidepressants.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Initial 3 months, Reauthorization Plan Year

Other Criteria

N/A

6

ALECENSA

Products Affected

• Alecensa

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Recurrent ALK-positive non-small cell lung cancer (NSCLC), brain

metastases from ALK-positive NSCLC.

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

7

ALOSETRON

Products Affected

• Alosetron Hydrochloride

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

1) The requested drug is being prescribed for a biological female or a

person that self-identifies as a female with a diagnosis of severe diarrhea-

predominant irritable bowel syndrome (IBS) AND 2) Chronic IBS

symptoms lasting at least 6 months AND 3) Gastrointestinal tract

abnormalities have been ruled out AND 4) Inadequate response to one

conventional therapy (e.g., antispasmodics, antidepressants,

antidiarrheals).

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

8

ALPHA1-PROTEINASE INHIBITOR

Products Affected

• Prolastin-c

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For alpha1-proteinase inhibitor deficiency: Patient must have 1) clinically

evident emphysema and 2) pretreatment serum alpha1-proteinase inhibitor

level less than 11 micromol/L (80 mg/dL by radial immunodiffusion or 50

mg/dL by nephelometry).

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

9

ALUNBRIG

Products Affected

• Alunbrig

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Recurrent ALK-positive non-small cell lung cancer (NSCLC), brain

metastases from ALK-positive NSCLC.

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

10

AMBRISENTAN

Products Affected

• Ambrisentan

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

Pulmonary arterial hypertension (PAH) (World Health Organization

[WHO] Group 1): Diagnosis was confirmed by right heart catheterization.

For PAH new starts only: 1) Pretreatment mean pulmonary arterial

pressure is greater than 20 mmHg, 2) Pretreatment pulmonary capillary

wedge pressure is less than or equal to 15 mmHg, and 3) Pretreatment

pulmonary vascular resistance is greater than or equal to 3 Wood units.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

11

ARCALYST

Products Affected

• Arcalyst

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Prevention of gout flares in patients initiating or continuing urate-

lowering therapy.

Exclusion

Criteria

N/A

Required

Medical

Information

For prevention of gout flares in patients initiating or continuing urate-

lowering therapy (e.g., allopurinol) (new starts): 1) two or more gout

flares within the previous 12 months, AND 2) inadequate response,

intolerance or contraindication to maximum tolerated doses of a non-

steroidal anti-inflammatory drug (NSAID) and colchicine, AND 3)

concurrent use with urate-lowering therapy. For prevention of gout flares

in patients initiating or continuing urate-lowering therapy (e.g.,

allopurinol) (continuation): 1) patient must have achieved or maintained a

clinical benefit (i.e., a fewer number of gout attacks or fewer flare days)

compared to baseline, AND 2) continued use of urate-lowering therapy

concurrently with the requested drug.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

For prevention of gout flares: 4 months. Other: Plan Year

Other Criteria

N/A

12

ARMODAFINIL

Products Affected

• Armodafinil

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

1) The patient has a diagnosis of narcolepsy and the diagnosis is

confirmed by sleep lab evaluation OR 2) The patient has a diagnosis of

Shift Work Disorder (SWD) OR 3) The patient has a diagnosis of

obstructive sleep apnea (OSA) and the diagnosis is confirmed by

polysomnography.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

13

ASPARLAS

Products Affected

• Asparlas

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

Patient age 21 years or less

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

14

AUSTEDO

Products Affected

• Austedo

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Tourette's syndrome

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

15

AVONEX

Products Affected

• Avonex INJ 30MCG/0.5ML

• Avonex Pen

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

16

AYVAKIT

Products Affected

• Ayvakit

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Myeloid and lymphoid neoplasms with eosinophilia, gastrointestinal

stromal tumor (GIST) for unresectable, recurrent, or metastatic disease

without platelet-derived growth factor receptor alpha (PDGFRA) exon 18

mutation

Exclusion

Criteria

N/A

Required

Medical

Information

For myeloid and lymphoid neoplasms with eosinophilia, the patient meets

all of the following criteria: 1) the disease is FIP1L1- PDGFRA

rearrangement-positive, AND 2) The disease harbors a PDGFRA D842A

mutation, AND 3) The disease is resistant to imatinib. For GIST, the

patient meets either of the following criteria: 1) The disease harbors

PDGFRA exon 18 mutation, including PDGFRA D842V mutations, OR

2) The requested drug will be used after failure on at least two Food and

Drug Administration (FDA)-approved therapies in unresectable,

recurrent, or metastatic disease without PDGFRA exon 18 mutation. For

advanced systemic mastocytosis (AdvSM): 1) the patient has a diagnosis

of advanced systemic mastocytosis including aggressive systemic

mastocytosis (ASM), systemic mastocytosis with associated

hematological neoplasm (SM-AHN), and mast cell leukemia (MCL) AND

2) the patient has a platelet count of greater than or equal to 50,000/mcL.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

17

BALVERSA

Products Affected

• Balversa

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

18

BANZEL

Products Affected

• Banzel TABS

• Rufinamide

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

1 year of age or older

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

19

BELEODAQ

Products Affected

• Beleodaq

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Adult T-cell leukemia/lymphoma, mycosis fungoides/Sezary syndrome,

extranodal NK/T-cell lymphoma (nasal type), hepatosplenic gamma-delta

T-cell lymphoma, and primary cutaneous anaplastic large cell lymphoma

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

20

BENLYSTA

Products Affected

• Benlysta

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

For patients new to therapy: severe active central nervous system lupus.

Required

Medical

Information

For systemic lupus erythematosus (SLE): 1) Patient is currently receiving

a stable standard therapy regimen (e.g., corticosteroid or antimalarial) for

SLE OR 2) patient is not currently receiving stable standard therapy

regimen for SLE because patient tried and had an inadequate response or

intolerance to stable standard therapy regimen. For lupus nephritis: 1)

Patient is currently receiving a stable standard therapy regimen (e.g.,

corticosteroid) for lupus nephritis OR 2) patient is not currently receiving

a stable standard therapy regimen for lupus nephritis because patient tried

and had an inadequate response or intolerance to a stable standard therapy

regimen.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

21

BESREMI

Products Affected

• Besremi

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

22

BETASERON

Products Affected

• Betaseron

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

23

BEVACIZUMAB

Products Affected

• Zirabev

24

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Breast cancer, central nervous system (CNS) tumor types: adult low-grade

(WHO Grade II) infiltrative supratentorial

astrocytoma/oligodendroglioma, adult intracranial and spinal

ependymoma, anaplastic gliomas, adult medulloblastoma, primary central

nervous system lymphoma, meningiomas, limited and extensive brain

metastases, and metastatic spine tumors, malignant pleural mesothelioma,

ovarian cancer/fallopian tube cancer/primary peritoneal cancer types:

carcinosarcoma (malignant mixed Mullerian tumors), clear cell

carcinoma, mucinous carcinoma, grade 1 endometrioid carcinoma, low-

grade serous carcinoma, ovarian borderline epithelial tumors (low

malignant potential) with invasive implants, and malignant sex cord-

stromal tumors, soft tissue sarcoma types: angiosarcoma and solitary

fibrous tumor/hemangiopericytoma, uterine neoplasms, endometrial

cancer, vulvar squamous cell carcinoma, and ophthalmic-related

disorders: diabetic macular edema, neovascular (wet) age-related macular

degeneration including polypoidal choroidopathy and retinal angiomatous

proliferation subtypes, macular edema following retinal vein occlusion,

proliferative diabetic retinopathy, choroidal neovascularization,

neovascular glaucoma and retinopathy of prematurity, small bowel

adenocarcinoma.

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

Coverage under Part D will be denied if coverage is available under Part

A or Part B as the medication is prescribed and dispensed or administered

for the individual.

25

BEXAROTENE

Products Affected

• Bexarotene

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Mycosis fungoides, Sezary syndrome, CD30-positive primary cutaneous

anaplastic large cell lymphoma, CD30-positive lymphomatoid papulosis.

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

26

BLENREP

Products Affected

• Blenrep

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

27

BOSENTAN

Products Affected

• Bosentan

• Tracleer TBSO

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For pulmonary arterial hypertension (PAH) (World Health Organization

[WHO] Group 1): Diagnosis was confirmed by right heart catheterization.

For PAH new starts only: 1) Pretreatment mean pulmonary arterial

pressure is greater than 20 mmHg, 2) Pretreatment pulmonary capillary

wedge pressure is less than or equal to 15 mmHg, and 3) Pretreatment

pulmonary vascular resistance is greater than or equal to 3 Wood units.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

28

BOSULIF

Products Affected

• Bosulif

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+

ALL)

Exclusion

Criteria

N/A

Required

Medical

Information

For chronic myeloid leukemia (CML) or acute lymphoblastic leukemia

(ALL): Diagnosis was confirmed by detection of the Philadelphia

chromosome or BCR-ABL gene. For CML, including patients newly

diagnosed with CML and patients who have received a hematopoietic

stem cell transplant: patient has experienced resistance or intolerance to

imatinib or dasatinib. If patient experienced resistance to an alternative

tyrosine kinase inhibitor for CML, patient is negative for all of the

following mutations: T315I, G250E, V299L, and F317L.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

29

BRAFTOVI

Products Affected

• Braftovi CAPS 75MG

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Adjuvant systemic therapy for cutaneous melanoma

Exclusion

Criteria

N/A

Required

Medical

Information

For colorectal cancer: The patient must meet both of the following

criteria: 1) Tumor is positive for BRAF V600E mutation, 2) The

requested drug will be used for either of the following: a) as subsequent

therapy for advanced or metastatic disease, or b) as primary treatment for

unresectable metachronous metastases. For cutaneous melanoma: The

patient must meet all of the following criteria: 1) Tumor is positive for

BRAF V600 activating mutation (e.g., V600E or V600K), 2) The

requested drug will be used in combination with binimetinib, and 3) The

requested drug will be used for either of the following: a) unresectable or

metastatic disease, or b) adjuvant systemic therapy.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

30

BRIVIACT

Products Affected

• Briviact ORAL SOLN

• Briviact TABS

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

1) The patient has experienced an inadequate treatment response,

intolerance, or contraindication to a generic anticonvulsant AND 2) If the

patient is 4 years of age or older, the patient has experienced an

inadequate treatment response, intolerance, or contraindication to any of

the following: Aptiom, Vimpat, Xcopri, Spritam.

Age Restrictions

1 month of age or older

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

31

BRIVIACT INJ

Products Affected

• Briviact INJ

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

1) The patient has experienced an inadequate treatment response,

intolerance, or contraindication to a generic anticonvulsant AND 2) If the

patient is 4 years of age or older, the patient has experienced an

inadequate treatment response, intolerance, or contraindication to any of

the following: Aptiom, Vimpat, Xcopri, Spritam.

Age Restrictions

1 month of age or older

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

32

BRUKINSA

Products Affected

• Brukinsa

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

33

BUPRENORPHINE

Products Affected

• Buprenorphine Hcl SUBL

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

The requested drug is being prescribed for the treatment of opioid use

disorder AND patient meets one of the following: 1) The patient is

pregnant or breastfeeding, and the requested drug is being prescribed for

induction therapy and/or subsequent maintenance therapy for treatment of

opioid use disorder OR 2) The requested drug is being prescribed for

induction therapy for transition from opioid use to treatment of opioid use

disorder OR 3) The requested drug is being prescribed for maintenance

therapy for treatment of opioid use disorder in a patient who is intolerant

to naloxone.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

12 months

Other Criteria

N/A

34

BUPRENORPHINE PATCH

Products Affected

• Buprenorphine PTWK

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

1) The requested drug is being prescribed for pain associated with cancer,

sickle cell disease, a terminal condition, or pain being managed through

palliative care OR 2) The requested drug is being prescribed for pain

severe enough to require daily, around-the-clock, long-term treatment in a

patient who has been taking an opioid AND 3) The patient can safely take

the requested dose based on their history of opioid use [Note: This drug

should be prescribed only by healthcare professionals who are

knowledgeable in the use of potent opioids for the management of chronic

pain.] AND 4) The patient has been evaluated and the patient will be

monitored for the development of opioid use disorder AND 5) This

request is for continuation of therapy for a patient who has been receiving

an extended-release opioid agent for at least 30 days OR the patient has

taken an immediate-release opioid for at least one week.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

35

CABOMETYX

Products Affected

• Cabometyx

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Non-small cell lung cancer

Exclusion

Criteria

N/A

Required

Medical

Information

For renal cell carcinoma: The disease is advanced, relapsed, or stage IV.

For non-small cell lung cancer: 1) The disease is rearranged during

transfection (RET) positive AND 2) the disease is recurrent, advanced, or

metastatic. For hepatocellular carcinoma: the requested drug will be used

as subsequent treatment.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

36

CALCIPOTRIENE

Products Affected

• Calcipotriene CREA

• Calcipotriene OINT

• Calcipotriene SOLN

• Calcipotriene/betamethasone

Dipropionate OINT

• Calcitriol OINT

• Enstilar

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

1) The requested drug is being prescribed for the treatment of psoriasis

AND 2) The patient experienced an inadequate treatment response,

intolerance, or the patient has a contraindication to a topical steroid.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

37

CALQUENCE

Products Affected

• Calquence

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Waldenstrom macroglobulinemia/lymphoplasmacytic lymphoma

Exclusion

Criteria

N/A

Required

Medical

Information

For chronic lymphocytic leukemia or small lymphocytic lymphoma: the

patient has experienced an intolerable adverse event with ibrutinib.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

38

CAPLYTA

Products Affected

• Caplyta

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

The patient experienced an inadequate treatment response, intolerance, or

contraindication to one of the following generic products: A) aripiprazole,

B) asenapine, C) olanzapine, D) quetiapine, E) risperidone, F) ziprasidone

AND the patient experienced an inadequate treatment response,

intolerance, or contraindication to one of the following brand products: A)

Latuda, B) Rexulti, C) Secuado.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

39

CAPRELSA

Products Affected

• Caprelsa

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Differentiated thyroid carcinoma: papillary, follicular, and Hurthle cell.

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

40

CARAC

Products Affected

• Fluorouracil CREA 0.5%

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

Patients who are pregnant or may become pregnant. Patients with

dihydropyrimidine dehydrogenase (DPD) enzyme deficiency.

Required

Medical

Information

If being used as part of a compounded product, all active ingredients in

the compounded product are FDA approved for topical use.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

3 months

Other Criteria

N/A

41

CARBAGLU

Products Affected

• Carbaglu

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For N-acetylglutamate synthase (NAGS) deficiency: Diagnosis of NAGS

deficiency was confirmed by enzymatic or genetic testing.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

42

CAYSTON

Products Affected

• Cayston

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For treatment of respiratory symptoms in cystic fibrosis patients: 1)

Pseudomonas aeruginosa is present in the patient's airway cultures OR 2)

The patient has a history of pseudomonas aeruginosa infection or

colonization in the airways.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

43

CERDELGA

Products Affected

• Cerdelga

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For Gaucher disease, the diagnosis was confirmed by an enzyme assay

demonstrating a deficiency of beta-glucocerebrosidase enzyme activity or

by genetic testing. The patient's CYP2D6 metabolizer status has been

established using an FDA-cleared test. The patient is a CYP2D6 extensive

metabolizer, an intermediate metabolizer, or a poor metabolizer.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

44

CHANTIX

Products Affected

• Apo-varenicline

• Chantix TABS 0.5MG, 1MG

• Chantix Continuing Month Pak

• Chantix Starting Month Pak

• Varenicline Tartrate

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

6 months

Other Criteria

This Prior Authorization requirement applies after the member has

received a cumulative 24 weeks of therapy in a Plan Year.

45

CHLORDIAZEPOXIDE - 65

Products Affected

• Chlordiazepoxide Hcl CAPS 10MG,

5MG

• Chlordiazepoxide Hydrochloride

CAPS 25MG

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For all indications: the prescriber must acknowledge the benefit of

therapy with the prescribed medication outweighs the potential risks for

the patient. (Note: The American Geriatrics Society identifies the use of

this medication as potentially inappropriate in older adults, meaning it is

best avoided, prescribed at reduced dosage, or used with caution or

carefully monitored.) For the management of anxiety disorders: 1) the

requested drug is being used concurrently with a selective serotonin

reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor

(SNRI) until SSRI/SNRI is effective for the symptoms of anxiety, OR 2)

the patient has experienced an inadequate treatment response, intolerance,

or has a contraindication to AT LEAST TWO agents from the following

classes: a) selective serotonin reuptake inhibitors (SSRIs), OR b)

serotonin-norepinephrine reuptake inhibitors (SNRIs).

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Short-term relief anxiety-preop apprehens and anx-1 mo, Anxiety

Disorder-4 mo, Alc Withdrawal-PlanYR

Other Criteria

This Prior Authorization requirement only applies to patients 65 years of

age or older.

46

CLOBAZAM

Products Affected

• Clobazam

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

2 years of age or older

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

47

CLOMIPRAMINE

Products Affected

• Clomipramine Hcl CAPS

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Depression, Panic Disorder

Exclusion

Criteria

N/A

Required

Medical

Information

1) The requested drug is being prescribed for one of the following:

Obsessive-Compulsive Disorder (OCD) or Panic Disorder AND 2) The

patient has experienced an inadequate treatment response, intolerance, or

the patient has a contraindication to any of the following: a serotonin and

norepinephrine reuptake inhibitor (SNRI) or a selective serotonin

reuptake inhibitor (SSRI) OR 3) The requested drug is being prescribed

for Depression AND 4) The patient has experienced an inadequate

treatment response, intolerance, or the patient has a contraindication to

two of the following: serotonin and norepinephrine reuptake inhibitors

(SNRIs), selective serotonin reuptake inhibitors (SSRIs), mirtazapine,

bupropion.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

48

CLORAZEPATE

Products Affected

• Clorazepate Dipotassium TABS

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For all indications: the prescriber must acknowledge the benefit of

therapy with the requested drug outweighs the potential risks for the

patient. (Note: The American Geriatrics Society identifies the use of this

medication as potentially inappropriate in older adults, meaning it is best

avoided, prescribed at reduced dosage, or used with caution or carefully

monitored.) For the management of anxiety disorders: 1) the requested

drug is being used concurrently with a selective serotonin reuptake

inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI)

until the SSRI/SNRI becomes effective for the symptoms of anxiety OR

2) the patient has experienced an inadequate treatment response,

intolerance, or has a contraindication to AT LEAST TWO agents from the

following classes: a) selective serotonin reuptake inhibitors (SSRIs) OR

b) serotonin-norepinephrine reuptake inhibitors (SNRIs).

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Short-term relief anxiety-1 month, Anxiety Disorders-4 months, All other

Diagnoses-Plan Year

Other Criteria

This Prior Authorization requirement only applies to patients 65 years of

age or older.

49

CLOZAPINE ODT

Products Affected

• Clozapine Odt

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

50

COLY-MYCIN

Products Affected

• Colistimethate Sodium INJ

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

Intravenous (IV) or intramuscular (IM) use only. Administration will not

be via nebulizer. (Note: CMS endorsed compendia do not support

inhalation/nebulization of colistimethate.). The infection is proven or

strongly suspected to be caused by susceptible bacteria based on: 1)

culture and susceptibility information OR 2) local epidemiology and

susceptibility patterns.

Age Restrictions

N/A

Prescriber

Restrictions

Prescribed by or in consultation with an infectious disease specialist

Coverage

Duration

Initial approval: 3 months, Renewal: Plan Year

Other Criteria

N/A

51

COMETRIQ

Products Affected

• Cometriq

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Non-small cell lung cancer (NSCLC), differentiated thyroid carcinoma:

papillary, follicular, and Hurthle cell.

Exclusion

Criteria

N/A

Required

Medical

Information

For NSCLC: The requested medication is used for NSCLC when the

patient's disease expresses rearranged during transfection (RET) gene

rearrangements.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

52

COPIKTRA

Products Affected

• Copiktra

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Gastric MALT lymphoma, non-gastric MALT lymphoma, nodal marginal

zone lymphoma, splenic marginal zone lymphoma

Exclusion

Criteria

N/A

Required

Medical

Information

For follicular lymphoma, gastric MALT lymphoma, non-gastric MALT

lymphoma, nodal marginal zone lymphoma, and splenic marginal zone

lymphoma: the requested drug will be used as subsequent therapy after at

least 2 prior therapies.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

53

COTELLIC

Products Affected

• Cotellic

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Central nervous system (CNS) cancer (i.e., glioma, meningioma,

astrocytoma)

Exclusion

Criteria

N/A

Required

Medical

Information

For adjuvant treatment of melanoma, and central nervous system (CNS)

cancer (i.e., glioma, meningioma, astrocytoma): The patient must meet

both of the following criteria: 1) The tumor is positive for BRAF V600

activating mutation (e.g., V600E or V600K), and 2) The requested drug

will be used in combination with vemurafenib. For unresectable or

metastatic melanoma: The patient must meet both of the following

criteria: 1) The tumor is positive for BRAF V600 activating mutation

(e.g., V600E or V600K), and 2) The requested drug will be used in

combination with vemurafenib (with or without atezolizumab).

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

54

CYSTAGON

Products Affected

• Cystagon

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For nephropathic cystinosis: Diagnosis of nephropathic cystinosis was

confirmed by the presence of increased cystine concentration in

leukocytes or by genetic testing.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

55

CYSTARAN

Products Affected

• Cystaran

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For cystinosis: 1) Diagnosis of cystinosis was confirmed by the presence

of increased cystine concentration in leukocytes or by genetic testing, and

2) Patient has corneal cystine crystal accumulation.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

56

DALFAMPRIDINE

Products Affected

• Dalfampridine Er

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For multiple sclerosis, patient must meet the following: For new starts,

prior to initiating therapy, patient meets the following: patient

demonstrates sustained walking impairment. For continuation of therapy,

patient meets the following: patient must have experienced an

improvement in walking speed OR other objective measure of walking

ability since starting the requested drug.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

57

DAURISMO

Products Affected

• Daurismo

PA Criteria

Criteria Details

Indications

All FDA-approved Indications, Some Medically accepted Indications.

Off-Label Uses

Post induction therapy following response to previous therapy with the

same regimen for acute myeloid leukemia (AML). Relapsed/refractory

AML as a component of repeating the initial successful induction

regimen.

Exclusion

Criteria

N/A

Required

Medical

Information

For acute myeloid leukemia: 1) the requested medication must be used in

combination with cytarabine, 2) the patient is 75 years of age or older OR

has comorbidities that preclude intensive chemotherapy, and 3) the

requested medication will be used as treatment for induction therapy,

post-induction therapy, or relapsed or refractory disease.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

58

DEFERASIROX

Products Affected

• Deferasirox

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

For chronic iron overload due to blood transfusions: pretreatment serum

ferritin level is greater than 1000 mcg/L.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

59

DEMSER

Products Affected

• Metyrosine

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

60

DESVENLAFAXINE

Products Affected

• Desvenlafaxine Er

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

Patient has experienced an inadequate treatment response, intolerance, or

the patient has a contraindication to TWO of the following: serotonin and

norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake

inhibitors (SSRIs), mirtazapine, bupropion.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

61

DHE NASAL

Products Affected

• Dihydroergotamine Mesylate

NASAL SOLN

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

1) The patient has experienced an inadequate treatment response to one

triptan 5-HT1 receptor agonist OR 2) The patient has experienced an

intolerance to one triptan 5-HT1 receptor agonist OR 3) The patient has a

contraindication that would prohibit a trial of triptan 5-HT1 receptor

agonists.

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

62

DIACOMIT

Products Affected

• Diacomit

PA Criteria

Criteria Details

Indications

All FDA-approved Indications.

Off-Label Uses

N/A

Exclusion

Criteria

N/A

Required

Medical

Information

N/A

Age Restrictions

N/A

Prescriber

Restrictions

N/A

Coverage

Duration

Plan Year

Other Criteria

N/A

63

DIAZEPAM

Products Affected

• Diazepam CONC

• Diazepam INJ 5MG/ML

• Diazepam ORAL SOLN 5MG/5ML

• Diazepam TABS